UTILIZATION MANAGEMENT PROGRAM DESCRIPTION MEDICAL ASSOCIATES HEALTH PLANS 2019 AUTHORITY Medical Associates Health Plan, Inc. and Medical Associates Clinic Health Plan of Wisconsin (collectively doing business as Medical Associates Health Plans and hereafter referred to as MAHP) have entered into contractual relationships or services agreements to make provision for medical and hospital services to enrollees. Medical Associates Health Plan, Inc. is licensed to do business as a health maintenance organization in the state of Iowa and Illinois. Medical Associates Clinic (sole shareholder of Medical Associates Health Plan of Wisconsin, and hereafter referred to as Clinic) has agreed to establish standards and procedures to assure the quality of health care rendered to health care providers, at the request of the Board of Directors of Medical Associates Health Plan, Inc. and Medical Associates Clinic Health Plan of Wisconsin. The Utilization Management Committee (UMC) is delegated by the Clinic Board of Directors to carry out utilization management duties. The members of the Committee are appointed by the Chief Medical Officer, report to the Quality Improvement Committee (QIC), and are responsible to the Clinic Board of Directors. Members are appointed on a rotating basis so that a portion of the membership remains each year to assure the continuity of the quality improvement process. OBJECTIVES/GOALS Objectives and Goals of the Medical Associates Health Plan and Utilization Management (UM) Plan are: To provide a monitoring system to assure that services are delivered to the enrollees at the appropriate level of care in a timely, effective, and cost efficient manner. To continually improve the quality of care and resource allocation within the organization. To utilize studies of patterns and utilization of health services for improved patient care and continuing education of the medical staff, administration, and consumer regarding health care cost containment. To evaluate advancing medical technologies to determine the level of coverage provided to enrollees. COMMITTEE STRUCTURES The committee consists of the following persons: Medical Associates Clinic Chief Medical Officer (CMO) or physician designee Director of Quality and Health Care Services Manager of Utilization Management Care Coordination Manager At least six other practitioners representing various specialties, appointed and re-appointed by the CMO based upon plan need for areas of focus, provider specialty, willingness to serve and understanding of managed care principles. Practitioners must be Health Plan Providers. As a member of the UMC, a designated behavioral healthcare physician or a doctorate level behavioral health practitioner is responsible for implementation of the behavioral health aspects of the UM program and review of the BH policies or new policies. (pgs.4&5) The behavioral healthcare practitioner must be a physician or have a clinical PhD or PsyD. Members will serve a three-year (3) term with one-third of membership rotating each year. Attendance is expected at 75 % of the meetings and excused absences count as attendance. Members not meeting this minimum attendance requirement will be subject to replacement as determined by the MAHP CMO or designated physician. Only practitioners may vote on matters concerning medical judgment and make an adverse determination relative to medical care delivery. No Committee member will be asked to review any case in which he/she is professionally involved. Consultation with non-Committee Board-Certified practitioners may be utilized if deemed necessary by the Chairperson. The Chairperson shall be the CMO or designated physician. UM Program Description Page 2 COMMITTEE OPERATION Meetings are held quarterly or more frequently if deemed necessary by the CMO or designated physician. The CMO or designated physician will report quarterly to the QIC, the Clinic Board of Directors and the Medical Associates Health Plans Board of Directors. The CMO or designee will be involved in the implementation, supervision, oversight and evaluation of the program. Utilization management activities apply to all MAHP enrollees and providers (including Community Plan members and providers). MAHP Medicare members must abide by the Medicare coverage guidelines. Local Coverage Decisions (LCD) and National Coverage Decisions (NCD) will be taken into consideration during the decision making process for these members. However, review efforts may be focused on utilization management trends and identified problem areas. Trends of utilization concerns are identified and become the focus of committee review and intervention as necessary. If the Committee determines that there are no problems, certain conditions, practitioners and procedures may be exempted from review. Such exemptions must receive prior Committee approval. Results of prospective, concurrent and retrospective data collection will provide this evidence. Minutes and records will be considered confidential and available only to the Committee, the Clinic Board of Directors, the MAHP Board of Directors, and external review organizations or accrediting agencies. Minutes will contain attendance records indicating those physicians present and those absent. The Utilization Management Committee Minutes will reflect all committee decisions, summary of discussions, and actions. Minutes are signed and dated by the person taking the minutes when they are completed. Minutes will be produced and distributed prior to the next Utilization Management meeting and are approved by the Utilization Management Committee. All review work sheets will be maintained in locked files for the purpose of confidentiality. Such MAHP cases will be reviewed for medical necessity, appropriate level of care for admission, continued stay and timely discharge, unless data collection justifies exempting review of this specific category as listed above. COMMITTEE SCOPE/FUNCTIONS The functions of the Committee may be executed by the entire Committee, a subcommittee, or by delegated members as deemed appropriate by the Committee. The Committee responsibilities and functions include but are not limited to: Assist in the development of policies and procedures as they relate to the functions of the MAHP and provide recommendations for implementation and evaluation to the QIC and Clinic Board of Directors. Review utilization reporting and UM work group recommendations for improvement of population health. Review requests for the MAHP coverage of new medical technologies and advancements and make recommendations to the QIC and Clinic Board of Directors. Review, monitor and measure success of quality improvement initiatives. Review and monitor hospital admissions involving all MAHP enrollees in accordance with applicable statutes and regulations. This will be done by concurrent or retrospective auditors. Monitor compliance of all providers with the pre-admission and referral processes. Make recommendation for action when non-compliance occurs. Review and monitor all out-of-plan referrals. The Committee should analyze practitioner referral patterns for appropriateness and recommend action to the Clinic Board of Directors. Review and monitor emergency room utilization and make recommendations for the correction of utilization concerns. Monitor the volume of and rationale behind the issuance of MAHP non-certifications of coverage. Review Pharmacy data quarterly to establish and maintain an effective drug utilization review system including: member utilization, practitioner prescribing patterns, pharmacy utilization, generic drug utilization, and the monitoring of formulary compliance. Review and monitor Health Care Services Case Management and Utilization Management medical necessity decisions. The CMO or designated physician will be available on an ongoing basis to the Health Care Services Case Managers for daily consultation. Provide education related to MAHP managed care model to the members of the Committee. The CMO, Director of Quality and Health Care Services & the Managers of Health Care Services Departments will be responsible for revising the Utilization Management Program Description and Work Plan on an annual basis. Amendments and addendums will be submitted to the UMC, QIC, and Clinic Board of Directors for ratification. MONITORING OF PRACTITIONER UTILIZATION Under the direction of the Clinic Board of Directors, the monitoring of individual practitioner and specialty utilization is the responsibility of the Utilization Management Committee. The Committee identifies concerns in the areas of hospital, UM Program Description Page 3 ambulatory care, prescription drug, out-of-area referral, and under-and over-utilization through a very critical analysis of comparative practitioner data including external data. Once outliers are identified, data will be shared with these practitioners for the purpose of generating discussions regarding possible corrective actions. Corrective action plans will be forwarded to the QIC, and Clinic Board of Directors in the form of a recommendation. It will be the responsibility for the Clinic Board to implement the recommendation. REVIEW OF HOSPITAL CLAIMS As directed by the CMO, meetings will be held with specialty departments to review hospital medical records and hospital claims. The purpose of these meetings is to review and consider the elimination of costly services/equipment, yet not jeopardizing the quality of care of the patient. Any cost-saving measure identified,